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Rees CE, Proctor DW, Nguyen VNB, Ottrey E, Mattick KL. Realist analysis of qualitative data in health professions education research. MEDICAL EDUCATION 2024. [PMID: 39157923 DOI: 10.1111/medu.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/29/2024] [Accepted: 07/09/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Qualitative realist analysis is gaining in popularity in health professions education research (HPER) as part of theory-driven program evaluation. Although realist approaches such as syntheses and evaluations typically advocate mixed methods, qualitative data dominate currently. Various forms of qualitative analysis have been articulated in HPER, yet realist analysis has not. Although realist analysis is interpretive, it moves beyond description to explain generative causation employing retroductive theorising. Ultimately, it attempts to build and/or 'test' (confirm, refute or refine) theory about how, why, for whom, when and to what extent programs work using the context-mechanism-outcome configuration (CMOC) heuristic. This paper aims to help readers better critique, conduct and report qualitative realist analysis. REALIST ANALYSIS METHODS We describe four fundamentals of qualitative realist analysis: (1) simultaneous data collection/analysis; (2) retroductive theorising; (3) configurational analysis (involving iterative phases of identifying CMOCs, synthesising CMOCs into demi-regularities and translating demi-regularities into program theory); and (4) realist analysis quality (relevance, rigour, richness). Next, we provide a critical analysis of realist analyses employed in 15 HPER outputs-three evaluations and 12 syntheses. Finally, drawing on our understandings of realist literature and our experiences of conducting qualitative realist analysis (both evaluations and syntheses), we articulate three common analysis challenges (coding, consolidation and mapping) and strategies to mitigate these challenges (teamwork, reflexivity and consultation, use of data analysis software and graphical representations of program theory). CONCLUSIONS Based on our critical analysis of the literature and realist analysis experiences, we encourage researchers, peer reviewers and readers to better understand qualitative realist analysis fundamentals. Realist analysts should draw on relevant realist reporting standards and literature on realist analysis to improve the quality and reporting of realist analysis. Through better understanding the common challenges and mitigation strategies for realist analysis, we can collectively improve the quality of realist analysis in HPER.
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Affiliation(s)
- Charlotte E Rees
- School of Health Sciences, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia
- Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | - Van N B Nguyen
- Monash Nursing & Midwifery, Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ella Ottrey
- Monash Centre for Scholarship in Health Education (MCSHE), Faculty of Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Karen L Mattick
- University of Exeter Medical School, University of Exeter, Exeter, UK
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Price T, Reynolds E, O'Brien T, Gale T, Quick O, Bryce M. Role of remediation in cases of serious misconduct before UK healthcare regulators: a qualitative study. BMJ Qual Saf 2024:bmjqs-2024-017187. [PMID: 39107109 DOI: 10.1136/bmjqs-2024-017187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 07/16/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND The raison d'etre of healthcare profession regulators across the globe is to protect patients and the public from the risk of harm. In cases of serious misconduct, remediation is deemed to be an important factor when considering the risk of harm from a practitioner under investigation. Yet, we know very little about how regulators account for remediation in their decision-making, and whether it is consistent with the aim of risk reduction. This paper explores the role of remediation in decision-making in cases of serious misconduct before UK healthcare regulators. METHODS We conducted interviews with 21 participants from across eight of the nine UK healthcare profession regulators, covering a range of roles in the decision-making process in misconduct cases. Interviews were conducted remotely by video call and digitally transcribed. Data were analysed using the framework analysis method. The initial framework was developed from existing literature and guidance documents from the regulators, and was subsequently refined through the various rounds of coding. RESULTS Remediation influenced decision-making in three ways: (1) Some types of misconduct were deemed more inherently remediable than others. In cases involving dishonesty or sexual misconduct, remediation was less likely to serve as a mitigating factor. (2) Decision-makers often view remediation as a proxy indicator of practitioner insight. (3) Whether a practitioner had demonstrated their commitment to change through undergoing remediation was more likely to feed into decision-making at the point where current impairment was under consideration. CONCLUSIONS Remediation plays a key role in decision-makers' judgements in cases of misconduct, particularly when these cases relate to clinical misconduct. In such cases, remediation informs judgements on the levels of practitioner insight and the risk of such misconduct being repeated. Our results suggest a need to develop remediation interventions that are explicitly geared towards the regulatory function of developing practitioner insight. Regulators should also consider the structure of their fitness to practise processes and whether there are appropriate opportunities for judgements on remediation to feed into decisions and to facilitate balanced and proportionate outcomes.
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Affiliation(s)
- Tristan Price
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Ellie Reynolds
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | | | - Thomas Gale
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Oliver Quick
- University of Bristol Law School, University of Bristol, Bristol, UK
| | - Marie Bryce
- Peninsula Medical School, University of Plymouth, Plymouth, UK
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McLeod K, Woodward-Kron R, Rashid P, Archer J, Nestel D. "I'm on an island": A qualitative study of underperforming surgical trainee perspectives on remediation. Am J Surg 2024; 234:11-16. [PMID: 38350749 DOI: 10.1016/j.amjsurg.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/14/2023] [Accepted: 01/28/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND There is a significant gap in the literature regarding trainees' perceptions of remediation. This study aims to explore surgical trainees' experiences and perspectives of remediation. METHODS This qualitative study used semi-structured interviews with 11 doctors who have experienced formal remediation as a surgical trainee. Reflexive thematic analysis was used for data analysis. RESULTS In this study, trainees perceived remediation as a harrowing and isolating experience, with long-lasting emotions. There was a perceived lack of clarity regarding explanations of underperformance and subjective goals. Remediation was viewed as a 'performance' and tick-box exercise with superficial plans, with challenging trainee/supervisor dynamics. CONCLUSIONS These findings about trainees' perspectives on remediation show a need for trainees to be better emotionally supported during remediation and that remediation plans must be improved to address deficits. Integrating the perspectives and experiences of surgical trainees who have undergone remediation should help improve remediation outcomes and patient care.
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Affiliation(s)
- Kathryn McLeod
- Department of Urological Surgery, Barwon Health, University Hospital, Geelong, Australia; School of Medicine, Deakin University, Geelong, Australia; Department of Surgery (Austin), University of Melbourne, Heidelberg, Australia.
| | - Robyn Woodward-Kron
- Department of Medical Education, The University of Melbourne, Melbourne, Australia
| | - Prem Rashid
- Department of Urology, Port Macquarie Base Hospital, Rural Clinical School, The University of New South Wales, Port Macquarie, Australia
| | - Julian Archer
- School of Medicine and Dentistry, Griffith University, Gold Coast, Australia
| | - Debra Nestel
- Department of Surgery (Austin), University of Melbourne, Heidelberg, Australia
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Zhu A, Aitken SJ. Failing in the system or systemic failure? The inherent tension within surgical trainee underperformance and remediation. Am J Surg 2024; 234:9-10. [PMID: 38570218 DOI: 10.1016/j.amjsurg.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Alison Zhu
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney Local Health District, Concord West, NSW, Australia
| | - Sarah Joy Aitken
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney Local Health District, Concord West, NSW, Australia.
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Stringer G, Ferguson J, Walshe K, Grigoroglou C, Allen T, Kontopantelis E, Ashcroft DM. Locum doctors in English general practices: evidence from a national survey. Br J Gen Pract 2023; 73:e667-e676. [PMID: 37604697 PMCID: PMC10471140 DOI: 10.3399/bjgp.2023.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/16/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Locum doctors give practices flexibility to deliver patient services but there are concerns about the impact of locum working on continuity of care, patient safety, team function, and cost. AIM To explore locum working in English general practices, and understand why and where locum doctors were needed and how they were engaged, supported, perceived, and managed. DESIGN AND SETTING An online survey was sent to 3745 practices. METHOD Quantitative responses were analysed using frequency tables, t-tests, and correlations. Free-text responses were analysed using thematic analysis. RESULTS In total, 605 (16.2%) responses were returned between June and December 2021. Practices made frequent use of locums, preferring regular locums familiar with processes and patients. Disadvantages of agency locums included cost, lack of patient familiarity, and impact on continuity of care. Care provided by locums was generally viewed as the same but sometimes worse compared with permanent GPs. Some practices reported that locums did not always perform the full range of duties, resulting in increased workload for other staff. Practices were largely unfamiliar with national guidance for organisations engaging locums, and, although processes such as verifying documentation were conducted, far fewer responders reported providing feedback, support for revalidation, or professional development. CONCLUSION Locum working is an essential part of English general practice, but this research raises some concerns about the robustness of arrangements for locum working and the impact on quality and safety of care. Further research is needed about the clinical practice and performance of locums, and to explore how locum working can be organised in ways that assure safe and high-quality care.
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Affiliation(s)
- Gemma Stringer
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Jane Ferguson
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Kieran Walshe
- Alliance Manchester Business School, Institute for Health Policy and Organisation, University of Manchester, Manchester, UK
| | - Christos Grigoroglou
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Thomas Allen
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK; Danish Centre for Health Economics, University of Southern Denmark, Denmark
| | - Evangelos Kontopantelis
- National Institute for Health and Care Research School for Primary Care Research, Centre for Primary Care and Division of Informatics, Imaging and Data Science, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
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Ajjawi R, Bearman M, Molloy E, Noble C. The role of feedback in supporting trainees who underperform in clinical environments. Front Med (Lausanne) 2023; 10:1121602. [PMID: 37181376 PMCID: PMC10167016 DOI: 10.3389/fmed.2023.1121602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/03/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Underperformance in clinical environments can be costly and emotional for all stakeholders. Feedback is an important pedagogical strategy for working with underperformance - both formal and informal strategies can make a difference. Feedback is a typical feature of remediation programs, and yet there is little consensus on how feedback should unfold in the context of underperformance. Methods This narrative review synthesises literature at the intersections of feedback and underperformance in clinical environments where service, learning and safety need to be considered. We do so with a critical eye towards generating insights for working with underperformance in the clinical environment. Synthesis and discussion There are compounding and multi-level factors that contribute to underperformance and subsequent failure. This complexity overwrites simplistic notions of 'earned' failure through individual traits and deficit. Working with such complexity requires feedback that goes beyond educator input or 'telling'. When we shift beyond feedback as input to process, we recognise that these processes are fundamentally relational, where trust and safety are necessary for trainees to share their weaknesses and doubts. Emotions are always present and they signal action. Feedback literacy might help us consider how to engage trainees with feedback so that they take an active (autonomous) role in developing their evaluative judgements. Finally, feedback cultures can be influential and take effort to shift if at all. A key mechanism running through all these considerations of feedback is enabling internal motivation, and creating conditions for trainees to feel relatedness, competence and autonomy. Broadening our perceptions of feedback, beyond telling, might help create environments for learning to flourish.
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Affiliation(s)
- Rola Ajjawi
- Centre for Research in Assessment and Digital Learning, Deakin University, Melbourne, VIC, Australia
| | - Margaret Bearman
- Centre for Research in Assessment and Digital Learning, Deakin University, Melbourne, VIC, Australia
| | - Elizabeth Molloy
- Department of Medical Education, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Christy Noble
- Academy for Medical Education, Medical School, The University of Queensland, Herston, QLD, Australia
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Dada S, Dalkin S, Gilmore B, Hunter R, Mukumbang FC. Applying and reporting relevance, richness and rigour in realist evidence appraisals: Advancing key concepts in realist reviews. Res Synth Methods 2023; 14:504-514. [PMID: 36872619 DOI: 10.1002/jrsm.1630] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/08/2023] [Accepted: 02/26/2023] [Indexed: 03/07/2023]
Abstract
The realist review/synthesis has become an increasingly prominent methodological approach to evidence synthesis that can inform policy and practice. While there are publication standards and guidelines for the conduct of realist reviews, published reviews often provide minimal detail regarding how they have conducted some methodological steps. This includes selecting and appraising evidence sources, which are often considered for their 'relevance, richness and rigour.' In contrast to other review approaches, for example, narrative reviews and meta-analyses, the inclusion criteria and appraisal of evidence within realist reviews depend less on the study's methodological quality and more on its contribution to our understanding of generative causation, uncovered through the process of retroductive theorising. This research brief aims to discuss the current challenges and practices for appraising documents' relevance, richness and rigour and to provide pragmatic suggestions for how realist reviewers can put this into practice.
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Affiliation(s)
- Sara Dada
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland.,School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Sonia Dalkin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK.,Fuse (The Centre for Translational Research in Public Health), Northumbria University, Newcastle Upon Tyne, UK
| | - Brynne Gilmore
- UCD Centre for Interdisciplinary Research Education and Innovation in Health Systems (UCD IRIS Centre), School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland.,School of Nursing Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Rebecca Hunter
- Department of Nursing and Midwifery, University of Highlands and Islands, Inverness, UK
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Duddy C, Wong G. Grand rounds in methodology: when are realist reviews useful, and what does a 'good' realist review look like? BMJ Qual Saf 2023; 32:173-180. [PMID: 36585019 DOI: 10.1136/bmjqs-2022-015236] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/07/2022] [Indexed: 01/01/2023]
Abstract
Research in the quality and safety field often necessitates an approach that supports the development of an in-depth understanding of how a complex phenomenon occurs, or how an intervention works. Realist review is an increasingly popular form of evidence synthesis that provides a theory-driven, interpretive approach to secondary research. Realist reviews offer quality and safety researchers the opportunity to draw on diverse types of evidence to develop explanatory theory about how, when and for whom interventions 'work' or outcomes occur. The approach is flexible, iterative and practical, typically drawing on the experience of policymakers, practitioners and patients throughout the review. With the increasing use of realist reviews, some common misconceptions about the approach have become evident in the literature. This paper introduces what is involved when planning and conducting a realist review, and where the approach can offer most value, as well as outlining common challenges that researchers may face when adopting the approach, and recommended solutions. Our aim is to support researchers who are considering conducting a realist review to understand the key principles and concepts involved, and how they can go about producing high-quality work.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Vasey TV, Carroll SJ, Daniel M, Cargo M. Changing Primary School Children's Engagement in Active School Travel Using Safe Routes to School Interventions: A Rapid Realist Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9976. [PMID: 36011609 PMCID: PMC9408451 DOI: 10.3390/ijerph19169976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
Safe Routes to School (SR2S) interventions have been implemented in many economically developed countries to improve children's engagement in Active School Travel (AST). Evaluations have highlighted inconsistencies in SR2S intervention outcomes, raising questions as to how, why, and under what contextual conditions these interventions work. This review used a Rapid Realist Review (RRR) methodology to build, test, and refine an overarching program theory that unpicks the contextual factors and underlying mechanisms influencing children's engagement in AST. From the 45 included documents, 16 refined Context-Mechanism-Outcome Configurations (CMOCs) were developed and clustered into three partial program theories (i.e., implementor/implementation, child, and parent), with the associated mechanisms of: (1) School Reliance; (2) School Priority; (3) Fun; (4) Pride; (5) Perceived Safety; (6) Distrust; (7) Convenience; (8) Perceived Capabilities; and (9) Reassurance. The overarching program theory delineates the pathways between intervention implementation, children's motivation, parental decision-making, and children's engagement in AST. The findings suggest SR2S interventions can motivate children to engage in AST, but whether this motivation is translated into engagement is determined by parental decision-making. This review is novel for highlighting that many of the factors influencing parental decision-making are contextually driven and appear to be unaddressed by the current suite of SR2S intervention strategies. The review additionally highlights the complexity of parental perceptions of safety, with the traffic and the road environment shaping only part of this multidimensional mechanism. Practitioners and policymakers need to tailor SR2S interventions to local contexts to better influence parental decision-making for children's engagement in AST.
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Bourgeois-Law G, Regehr G, Teunissen PW, Varpio L. Strangers in a strange land: The experience of physicians undergoing remediation. MEDICAL EDUCATION 2022; 56:670-679. [PMID: 35080035 DOI: 10.1111/medu.14736] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The experience of remediation in practising physicians has not been widely studied. Remediatees frequently present negative emotions, but observers can only infer the underlying reasons behind these. Understanding remediatees' perspectives may help those mandating and organising remediation to structure the process in ways that improve the experience for all concerned parties and maximise chances of a successful outcome for remediatees. METHODS Seventeen physicians who had undergone remediation for clinical competence concerns were interviewed via telephone. Participant data were first iteratively analysed thematically and then reanalysed using a narrative mode of analysis for each participant in order to understand the stories as wholes. Figured worlds (FW) theory was used as a lens for analysing the data for this constructivist research study. RESULTS Participants entering the FW of remediation perceived that their position as a 'good doctor' was threatened. Lacking experience with this world and with little available support to help them navigate it, participants used their agency to draw on various discursive threads within the FW to construct a narrative account of their remediation. In their narratives, participants tended to position themselves either as victims of regulatory bodies or as resilient individuals who could make the best of a difficult situation. In both cases, the chosen discursive threads enabled them to maintain their self-identity as 'good doctor'. CONCLUSION Remediation poses a threat to a physician's professional and personal identity. Focusing mainly on the educational aspect of remediation-that is, the improvement in knowledge and skills-risks missing its impact on physician identity. We need to ensure not only that we support physicians in dealing with this identity threat but that our assessment and remediation processes do not inadvertently encourage remediatees to draw on discursive threads that lead them to see themselves as victims.
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Affiliation(s)
- Gisèle Bourgeois-Law
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Glenn Regehr
- Department of Surgery, University of British Columbia, Vancouver, Canada
- Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Pim W Teunissen
- School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Lara Varpio
- Graduate Programs in Health Professions Education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Cheong CWS, Quah ELY, Chua KZY, Lim WQ, Toh RQE, Chiang CLL, Ng CWH, Lim EG, Teo YH, Kow CS, Vijayprasanth R, Liang ZJ, Tan YKI, Tan JRM, Chiam M, Lee ASI, Ong YT, Chin AMC, Wijaya L, Fong W, Mason S, Krishna LKR. Post graduate remediation programs in medicine: a scoping review. BMC MEDICAL EDUCATION 2022; 22:294. [PMID: 35443679 PMCID: PMC9020048 DOI: 10.1186/s12909-022-03278-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Recognizing that physicians may struggle to achieve knowledge, skills, attitudes and or conduct at one or more stages during their training has highlighted the importance of the 'deliberate practice of improving performance through practising beyond one's comfort level under guidance'. However, variations in physician, program, contextual and healthcare and educational systems complicate efforts to create a consistent approach to remediation. Balancing the inevitable disparities in approaches and settings with the need for continuity and effective oversight of the remediation process, as well as the context and population specific nature of remediation, this review will scrutinise the remediation of physicians in training to better guide the design, structuring and oversight of new remediation programs. METHODS Krishna's Systematic Evidence Based Approach is adopted to guide this Systematic Scoping Review (SSR in SEBA) to enhance the transparency and reproducibility of this review. A structured search for articles on remediation programs for licenced physicians who have completed their pre-registration postings and who are in training positions published between 1st January 1990 and 31st December 2021 in PubMed, Scopus, ERIC, Google Scholar, PsycINFO, ASSIA, HMIC, DARE and Web of Science databases was carried out. The included articles were concurrently thematically and content analysed using SEBA's Split Approach. Similarities in the identified themes and categories were combined in the Jigsaw Perspective and compared with the tabulated summaries of included articles in the Funnelling Process to create the domains that will guide discussions. RESULTS The research team retrieved 5512 abstracts, reviewed 304 full-text articles and included 101 articles. The domains identified were characteristics, indications, frameworks, domains, enablers and barriers and unique features of remediation in licenced physicians in training programs. CONCLUSION Building upon our findings and guided by Hauer et al. approach to remediation and Taylor and Hamdy's Multi-theories Model, we proffer a theoretically grounded 7-stage evidence-based remediation framework to enhance understanding of remediation in licenced physicians in training programs. We believe this framework can guide program design and reframe remediation's role as an integral part of training programs and a source of support and professional, academic, research, interprofessional and personal development.
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Affiliation(s)
- Clarissa Wei Shuen Cheong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Elaine Li Ying Quah
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Keith Zi Yuan Chua
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Wei Qiang Lim
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Rachelle Qi En Toh
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Christine Li Ling Chiang
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Caleb Wei Hao Ng
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Elijah Gin Lim
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Yao Hao Teo
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Cheryl Shumin Kow
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Raveendran Vijayprasanth
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Zhen Jonathan Liang
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Yih Kiat Isac Tan
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Javier Rui Ming Tan
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Min Chiam
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Alexia Sze Inn Lee
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
| | - Yun Ting Ong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
| | - Annelissa Mien Chew Chin
- Medical Library, National University of Singapore Libraries, Blk MD6, Centre, 14 Medical Dr, #05-01 for Translational Medicine, Singapore, 117599 Singapore
| | - Limin Wijaya
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore, 169608 Singapore
| | - Warren Fong
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Department of Rheumatology and Immunology, Singapore General Hospital, 16 College Road, Block 6 Level 9, Singapore, 169854 Singapore
| | - Stephen Mason
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK
| | - Lalit Kumar Radha Krishna
- Yong Loo Lin School of Medicine, National University Singapore, 1E Kent Ridge Road, 119228 NUHS Tower Block, Level, Singapore, 11 Singapore
- Division of Supportive Palliative and Care, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 16961 Singapore
- Division of Cancer Education, National Cancer Centre Singapore, 11 Hospital Crescent, Singapore, 169610 Singapore
- Duke-NUS Medical School, 8 College Road, Singapore, 169857 Singapore
- Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, Cancer Research Centre, University of Liverpool, 200 London Road, Liverpool, L3 9TA UK
- Centre for Biomedical Ethics, National University of Singapore, Blk MD11, 10 Medical Drive, #02-03, Singapore, 117597 Singapore
- PalC, The Palliative Care Centre for Excellence in Research and Education, PalC c/o Dover Park Hospice, 10 Jalan Tan Tock Seng, Singapore, 308436 Singapore
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Bourgeois-Law G, Varpio L, Teunissen P, Regehr G. Remediation in Practice: A Polarity to be Managed. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2022; 42:130-134. [PMID: 34974506 DOI: 10.1097/ceh.0000000000000413] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Originally developed in the business literature, a polarity is a concept where 2 distinctive and opposing characteristics (poles), each presenting advantages and disadvantages or opportunities and pitfalls, must both be taken into account to ensure effective management of a challenging problem. Managing a polarity is a thorny endeavor because it entails striving to maximize the benefits of both poles while simultaneously minimizing or controlling the downsides of each. Previous investigations into stakeholder conceptualizations of remediation led us to suggest that remediation is framed in stakeholders' minds simultaneously as an educational endeavor (ie, the remediatee needs educational support to regain full competence) and a regulatory act (ie, the revocation of the individual's professional right to self-regulate their practice and learning). In this article, we argue that viewing remediation for practicing physicians as a polarity to be managed offers a framework that can further the conversation about how to address some of remediation's challenges.
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Affiliation(s)
- Gisèle Bourgeois-Law
- Dr. Bourgeois-Law: Clinical Professor, Department of Obstetrics and Gynecology, Faculty of Medicine, University of British Columbia, Vancouver, Canada. Dr. Varpio: Professor, Department of Medicine, and Associate Director of Research, Graduate Programs in Health Professions Education, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Dr. Regehr: Professor, Department of Surgery and Associate Director (Research), Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, Canada. Dr. Teunissen: Scientific and Research Director of the School of Health Professions Education (SHE), Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands, and Specialist Obstetrician Gynecologist, Maastricht University Medical Centre, Maastricht, the Netherlandsnp
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Brennan N. Emotions, psychological safety and recommendations for designing remediation programmes. MEDICAL EDUCATION 2022; 56:141-143. [PMID: 34761423 DOI: 10.1111/medu.14687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
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Colonnello V. Enhancing remediation by focusing on affective experience. MEDICAL EDUCATION 2021; 55:1338-1340. [PMID: 34558109 PMCID: PMC9293010 DOI: 10.1111/medu.14670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/17/2021] [Indexed: 05/02/2023]
Abstract
Colonnello offers the affective neuroscience view as a means for better understanding the role of emotions in remediation and nurturing synergistic interactions between research and education.
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Affiliation(s)
- Valentina Colonnello
- Department of Experimental, Diagnostic and Specialty MedicineUniversity of BolognaBolognaItaly
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Mills LM, Boscardin C, Joyce EA, Ten Cate O, O'Sullivan PS. Emotion in remediation: A scoping review of the medical education literature. MEDICAL EDUCATION 2021; 55:1350-1362. [PMID: 34355413 DOI: 10.1111/medu.14605] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 05/15/2023]
Abstract
OBJECTIVES Remediation can be crucial and high stakes for medical learners, and experts agree it is often not optimally conducted. Research from other fields indicates that explicit incorporation of emotion improves education because of emotion's documented impacts on learning. Because this could present an important opportunity for improving remediation, we aimed to investigate how the literature on remediation interventions in medical education discusses emotion. METHODS The authors used Arksey and O'Malley's framework to conduct a scoping literature review of records describing remediation interventions in medical education, using PubMed, CINAHL Complete, ERIC, Web of Science and APA PsycInfo databases, including all English-language publications through 1 May 2020 meeting search criteria. They included publications discussing remediation interventions either empirically or theoretically, pertaining to physicians or physician trainees of any level. Two independent reviewers used a standardised data extraction form to report descriptive information; they reviewed included records for the presence of mentions of emotion, described the mentions and analysed results thematically. RESULTS Of 1644 records, 199 met inclusion criteria and were reviewed in full. Of those, 112 (56%) mentioned emotion in some way; others focused solely on cognitive aspects of remediation. The mentions of emotion fell into three themes based on when the emotion was cited as present: during regular coursework or practice, upon referral for remediation and during remediation. One-quarter of records (50) indicated potential intentional incorporation of emotion into remediation programme design, but they were non-specific as to how emotions related to the learning process itself. CONCLUSION Even though emotion is omnipresent in remediation, medical educators frequently do not factor emotion into the design of remediation approaches and rarely explicitly utilise emotion to improve the learning process. Applications from other fields may help medical educators leverage emotion to improve learning in remediation, including strategies to frame and design remediation.
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Affiliation(s)
- Lynnea M Mills
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Christy Boscardin
- Department of Anaesthesia and Perioperative Care and Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Elizabeth A Joyce
- Department of Microbiology and Immunology, University of California, San Francisco, San Francisco, CA, USA
| | - Olle Ten Cate
- Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Patricia S O'Sullivan
- Departments of Medicine and Surgery, University of California, San Francisco, San Francisco, CA, USA
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Bourgeois-Law G. Remediation: The best CPD and vice versa. MEDICAL EDUCATION 2021; 55:989-990. [PMID: 34097770 DOI: 10.1111/medu.14582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 06/12/2023]
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Price T, Brennan N, Wong G, Withers L, Cleland J, Wanner A, Gale T, Prescott-Clements L, Archer J, Bryce M. Remediation programmes for practising doctors to restore patient safety: the RESTORE realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
An underperforming doctor puts patient safety at risk. Remediation is an intervention intended to address underperformance and return a doctor to safe practice. Used in health-care systems all over the world, it has clear implications for both patient safety and doctor retention in the workforce. However, there is limited evidence underpinning remediation programmes, particularly a lack of knowledge as to why and how a remedial intervention may work to change a doctor’s practice.
Objectives
To (1) conduct a realist review of the literature to ascertain why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to restore patient safety; and (2) provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors.
Design
A realist review of the literature underpinned by the Realist And MEta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.
Data sources
Searches of bibliographic databases were conducted in June 2018 using the following databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center, Database of Abstracts of Reviews of Effects, Applied Social Sciences Index and Abstracts, and Health Management Information Consortium. Grey literature searches were conducted in June 2019 using the following: Google Scholar (Google Inc., Mountain View, CA, USA), OpenGrey, NHS England, North Grey Literature Collection, National Institute for Health and Care Excellence Evidence, Electronic Theses Online Service, Health Systems Evidence and Turning Research into Practice. Further relevant studies were identified via backward citation searching, searching the libraries of the core research team and through a stakeholder group.
Review methods
Realist review is a theory-orientated and explanatory approach to the synthesis of evidence that seeks to develop programme theories about how an intervention produces its effects. We developed a programme theory of remediation by convening a stakeholder group and undertaking a systematic search of the literature. We included all studies in the English language on the remediation of practising doctors, all study designs, all health-care settings and all outcome measures. We extracted relevant sections of text relating to the programme theory. Extracted data were then synthesised using a realist logic of analysis to identify context–mechanism–outcome configurations.
Results
A total of 141 records were included. Of the 141 studies included in the review, 64% related to North America and 14% were from the UK. The majority of studies (72%) were published between 2008 and 2018. A total of 33% of articles were commentaries, 30% were research papers, 25% were case studies and 12% were other types of articles. Among the research papers, 64% were quantitative, 19% were literature reviews, 14% were qualitative and 3% were mixed methods. A total of 40% of the articles were about junior doctors/residents, 31% were about practicing physicians, 17% were about a mixture of both (with some including medical students) and 12% were not applicable. A total of 40% of studies focused on remediating all areas of clinical practice, including medical knowledge, clinical skills and professionalism. A total of 27% of studies focused on professionalism only, 19% focused on knowledge and/or clinical skills and 14% did not specify. A total of 32% of studies described a remediation intervention, 16% outlined strategies for designing remediation programmes, 11% outlined remediation models and 41% were not applicable. Twenty-nine context–mechanism–outcome configurations were identified. Remediation programmes work when they develop doctors’ insight and motivation, and reinforce behaviour change. Strategies such as providing safe spaces, using advocacy to develop trust in the remediation process and carefully framing feedback create contexts in which psychological safety and professional dissonance lead to the development of insight. Involving the remediating doctor in remediation planning can provide a perceived sense of control in the process and this, alongside correcting causal attribution, goal-setting, destigmatising remediation and clarity of consequences, helps motivate doctors to change. Sustained change may be facilitated by practising new behaviours and skills and through guided reflection.
Limitations
Limitations were the low quality of included literature and limited number of UK-based studies.
Future work
Future work should use the recommendations to optimise the delivery of existing remediation programmes for doctors in the NHS.
Study registration
This study is registered as PROSPERO CRD42018088779.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Tristan Price
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Nicola Brennan
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Jennifer Cleland
- Medical Education Research and Scholarship Unit (MERSU), Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Amanda Wanner
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | - Thomas Gale
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Julian Archer
- Medicine, Nursing and Health Sciences Education Portfolio, Monash University, Melbourne, VIC, Australia
| | - Marie Bryce
- Collaboration for the Advancement of Medical Education Research and Assessment (CAMERA), Faculty of Health, University of Plymouth, Plymouth, UK
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